Week 1: Guidelines, Studies, Lifestyle, Inpatient

Question 1

Therapy for obese patients with no complications and BMI <27 or BMI >27

Answer 1

lifestyle modifications, MDIRD counseling, web program for weight loss

Question 2

BMI >27 w complications treatment

Answer 2

low complication severity: lifestyle mod, med tx
medium severity: lifestyle, med
high: lifestyle mod, med, surgery (BMI>35)

Question 3

two conditions that need to be treated in pre DM

Answer 3

hyperlipidemia and HTN

Question 4

what happens if pre-DM progresses to overt?

Answer 4

Does pt have FPG>100 and/or 2=hePPG>140?
if just one consider increasing weight loss strategies
If both, consider metformin/acarbose + TZD/GLP-1RA w caution

Question 5

DM risk factors

Answer 5

CVD 
FH DM
dyslipidemia
HTN
sedentary
non-caucasian
overweight
metabolic syndrome
hx gestational DM
large child at birth

Question 6

Fasting BG for normal, Pre DM and DM

Answer 6

normal preDM DM

<100 100-125 >126

Question 7

2-hr post 75mg OGTT for normal, Pre DM and DM

Answer 7

normal preDM DM

<140 140-199 >200

Question 8

A1C normal, Pre DM and DM

Answer 8

normal preDM DM

<5.4% 5.5-6.4% >6.5%

Question 9

what causes an A1c to be misleading

Answer 9

Hgbinopathies
iron deficiency
hemolytic anemias
thalassemias
spherocytosis
severe hepatic or renal disease

Question 10

T1 DM characteristics

Answer 10

onset <20 yo usually
lean
onset is acute
ketosis present
usually white
Abs present

Question 11

T2 DM characteristics

Answer 11

>40 yo usually
obese
onset subtle and slow
FHx common
no Abs present

Question 12

When do we use strict targets for DM control? Which guideline? What parameters/goals? What color are the guidelines?

Answer 12

AACE (maroon and blue, wide)
<65 w no CVD

A1C <6.5%
FBG <110
PPG <140

Question 13

When do we use loose targets for DM control? Which guideline? What parameters/goals? What color are the guidelines?

Answer 13

AACE (yellow, green, light blue, skinny)
>65 or >65 w CVD

A1C <7.5%
FBG <80-130
PPG <180

Question 14

ADA guidelines
patient with….
ASCVD? HF? CKD? Dec. hypo-g? Weight loss? cost issue?

Answer 14

ASCVD HF CKD dec hypog
GLP1-RA SGLT2i SGLT2i DPP4i, GLP1RA,
SGLT2i (dapa, (cana, dapa) SGLT2i, TZD
empa) GLP-1RA (do two, then ins)
TZD
DPP4i
basal ins
SU

dec weight gain              cost issue
GLP1RA or SGLT2i          SU or TZD
                                         \+TZD or SU
\+DPP4i                       
                                          \+basal ins
\+SU
  TZD
   basal ins

Question 15

AACE guidelines tx

Answer 15

A1C<7.5% A1C7.5-9.0% >9.0%
(monotherapy) (and if est CKD, HFrEF) nosx-dual/triple
Metformin (dual therapy) sx-ins+/-other tx
SGLT2i SGLT2i
DPP4i DPP4i
TZD TZD middle column
AGi GU/GLN and right column
SU/GLN basal ins. go on to basal ins
Colesevelam then + prandial
AGi
(tripple if no improvement in 3 mo)

Question 16

How do we add basal and/or bolus insulin in AACE guidelines

Answer 16

Strict targets
If A1C <8%: 0.1-0.2 U/kg basal
If A1C >8%: 0.2-0.3 U/kg basal

If already on basal and are adding 1 bolus dose: 10% of basal dose or 5U
If starting basal AND bolus: 0.3-0.5U/kg/d, 50% basal and 50% prandial/3= per meal

Question 17

How do we add basal and/or bolus insulin in ADA guidelines

Answer 17

Loose targets
Adding basal: 0.1-0.2U/kg/d
Adding bolus: 4U each bolus or 10% of basal

Question 18

hypoglycemia s + sx stage 1

Answer 18

nervous                  pallor
anxiety                   diaphoresis
palpitations            tachy-c
hunger
tremors
nausea
angina
irritable
numbness/tingling

Question 19

hypoglycemia s + sx stage 2

Answer 19

sudden fatigue
weakness
feeling cold
transient hemiplagia
dizzy
HA
impaired mentation

confusion
amnesia
drowsiness
belligerence
irrationality
aphasia
seizures
coma
death

Question 20

hypoglycemia tx

Answer 20

Rule of 15: (first check BG to confirm) eat 15 g carbs (candy, oj, soda) and wait 15 min then re-check BG
follow up with substantial snack (protein, carb, fat)

Question 21

severe hypoglycemia tx

Answer 21

glucagon recombinant (Glucagon, GlucaGen)

Question 22

hyperglycemia s and sx

Answer 22

weakness
malaise
visual changes
polyuria
polyphagia
weight loss
nocturia

Question 23

home management of hyperglycemia

Answer 23

monitor BG frequently
insulin
rest
drink water
exercise

Question 24

microvascular complications

Answer 24

neuropathy, nephropathy, retinopathy

Question 25

macrovascular complications

Answer 25

``` cerebrovascular disease (CVA, aneurysm, hemorrhagic stroke) Heart Disease (CAD, angina, MI) PVD (PAD, ulcers, amputations) ```

Question 26

macrovascular management

Answer 26

BP control: goal <130/80mmHg ACEi, ARB, CCB, thiazides are first line + MRA for resistant HTN ``` cholesterol management: max statin +ezetimibe +PCSK9i +BAS +niacin ``` ASA tx primary prevention: if ASCVD >10% secondary prevention: all obesity management, smoking cessation immunizations: Influenza qyr, pneumococcus, HepB

Question 27

Which immunizations should diabetics receive

Answer 27

Influenza qyr, pneumococcus (19-64 yo = PPSV23, >65 yo = PCV13--1yr--> PPSV23), HepB all

Question 28

Retinopathy complications and when to monitor

Answer 28

hemorrhages, abnormal BV growth, aneurism, cotton wool spots. hard exudates optimize BP, BG, and lipid control T1DM: eye exam within 5 yrs of onset then q year T2DM: eye exam @ dx then q year

Question 29

Nephropathy risk factors, tx, monitoring,

Answer 29

RF: hyperglycemia, HTN, proteinuria, dyslipidemia Tx: SGLT2i or GLP1RA with CKD bennies (cana or dapa) Monitoring: asses urinary albumin and eGFR q year

Question 30

Neuropathy (DPN) dx, tx, monitoring, when to see specialist

Answer 30

dx of exclusion tx: Pregabalin, Duloxetine, Gabapentin Monitoring: Foot exam q year See specialist if smoker, poor BG control, hx of lower extremity issues, foot deformities, PAD, visual impairment, CKD

Question 31

What drugs cause hyperglycemia?

Answer 31

``` atypical APs BBs CCB corticosteroids fluoroquinolones niacin phenothiazines protease inhibitors thiazides ```

Question 32

What drugs cause hypoglycemia?

Answer 32

``` ACEi po anti-DM agents fibric acid derivatives SSAs + APAP SSRis quinine pentamidine MAOis ```

Question 33

DKA clinical presentation

Answer 33

thirst, hunger, abdominal pain, N/V, profound weakness, AMS | Kussmal respirations, acetone breath (fruity), hypothermia, tachycardia, dehydration, hypotonia

Question 34

DKA treatment

Answer 34

fluid replacement: 1-1.5L @ 250-500mL/hr (1/2NS if wnl Na, NS is Na low) once BG is <200 can switch to 1/2NS in D5W K replacement if needed Insulin therapy - check K+ before initiation want BG to decrease 50-75 in 1 hr, if it doesnt increase infusion rate until anion gap closes 0.1U/kg IV bolus --> 0.1U/kg/hr cont inf

Question 35

HHS (hyperosmolar hyperglycemic state) hx, PE, and treatment

Answer 35

hx: impaired consciousness, seizures PE: extreme dehydration Tx: fluid replacement (need more free H2O than with DKA) electrolytes (K, Mg, phos, Ca) insulin: check K+ before initiation 1-2U/h (do not exceed dec in BG >75-100/hr!) close inpatient monitoring: finger sticks q1-2h electrolytes q4h

Question 36

DCCT trial DM type? What was studied? outcome?

Answer 36

T1DM retin neuro and nephro pathy studied outcome: microvasc is A1C dependent, takes 10 yrs for CV bennies

Question 37

UKPDS trial DM type? What was studied? outcome?

Answer 37

``` T2DM metformin, SU, insulin microvasc issues favor intensive tx we <3 metformin 10 yr later trial analyzed long term decreasing A1C decreased DM related death, MI and micro issues ```

Question 38

ADVANCE trial DM type? What was studied? outcome?

Answer 38

T2DM micro and macro dec A1C helped nephropathy the most

Question 39

VADT trial DM type? What was studied? outcome?

Answer 39

``` T2DM and intensive control of BG # of hypoglycemic events in past 30 d is primary predictor of inc CV mortality ```

Question 40

Lifestyle Management

Answer 40

MNT (medical nutrition therapy) Physical activity (150+ min mod-vig aerobic/week) Smoking cessation

Question 41

Pediatric T1DM when to tx A1C goal screening/monitoring

Answer 41

tx if BP >130/80 +/or LDL-C>130 screen for microvascular complications once 10 y/o or has DM x5yrs goal A1C,7.5% MNT and exercise

Question 42

``` Pediatric T2DM when to dx weight loss goal screening/monitoring/management A1C goal tx what to do after Abs testing? ```

Answer 42

>10 y/o + BMI >85th percentile aim for 7-10% weight loss 30-60min exercise 5d/wk A1C goal <7% A1C <8.5% - metformin po BID up to 2,000mg/d A1C >8.5% - basal ins 0.5U/kg/d and metformin if no Abs - consider liraglutide, add prandialor cont basal if Abs - D/C Metformin and + pump insulin

Question 43

What is considered a sick day in DM? | How to manage?

Answer 43

infxn ,surgery, trauma, invasive op, major life stress ``` test BG q2h T1DM --> teset ketones monitor temp keep hydrated tx sx (N/V/thirst/pee) ``` continue basal ins at normal dose if patient is eating can cont rapid ins @ normal dose D/C all PO meds including Metformin, SGLT2i, GLP1RA if N/V --> D/C ALL PO MEDS

Question 44

``` Patient LM is a 70 y/o female who has had T2DM for 6 years. She is recovering from a femur fracture and surgery a week ago and begins to feel nauseous today in the afternoon. As the day goes on they become thirsty and have increased urination. She could not stomach lunch or dinner d/t nausea. PMH: HTN, T2DM, dyslipidemia Meds Basaglar U-100 qd Metformin ER 1000mg po BID Lisinopril 20 mg po qd Empagliflozin 10mg po qd Aspirin 81mg po qd Atorvastatin 40mg po qd ``` Is this considered a sick day? If so what should change about the med list? What should be done to tx?

Answer 44

Yes, this is a sick day because of the trauma, major life stressor and sx All po medications should be discontinued (if no NV, Lisinopril, Aspirin and Atorvastatin are homies) Basaglar can be continued since it is a basal insulin tx: test BG q2h monitor temp stay hydrated, track sx on sick day, continue all po meds except Metformin, SGLT2i, and GLP1 RA because dont want to tank BG while they are continuing basal insulin and are likely NPO

Question 45

gestational DM preferred tx

Answer 45

insulin>> | metformin and glyburide sparingly

Question 46

Upon admission, what should be checked for a patient w hx DM?

Answer 46

A1C and BG

Question 47

BG targets for an admitted DM patient who is not critically ill when to change tx

Answer 47

FBG <110 PPG <180 change tx if BG<100

Question 48

When to add correctional insulin | How many U?

Answer 48

Usually started with admission as BG is checked frequently. Also used when pt is on basal and prandial and BG is still uncontrolled ``` BG U <150--> 0U 150-199---> 2U 200-249--> 4U 250-299--> 6U 300-349---> 8U >350--------> 10U ```

Question 49

insulin related med errors causes

Answer 49

use of "U" insulin at floor stock many insulin concentrations available, non-standard Ko testing and reporting errors w BG testing

Question 50

DKA onset, clinical sx, BG, pH, anion gap, ketones, Osm

Answer 50

``` hrs -days onset polyuria, polydipsia, weight loss, vomiting BG >250 pH <7.3 anion gap >12 (+)ketones <320 Osm ```

Question 51

HHS onset, clinical sx, BG, pH, anion gap, ketones, Osm

Answer 51

``` days-wks onset polyuria, polydipsia, weight loss, vomiting BG >600 pH norm anion gap variable (-)ketones >320 Osm ```

Question 52

DKA/HHS precipitating factors

Answer 52

infxns, MI, meds, non-adherence, poor sick day management, pancreatitis, wrong dose/ D/C ins, new onset T1DM

Question 53

What are the BG goals in DKA and HHS?

Answer 53

DKA goal : 200 (>250 @ dx) | HHS goal: 300 (>600 @dx)

Question 54

When administering insulin for DKA/HHS, we measure K+ beforehand. What K+ values determine insulin use?

Answer 54

<3.3 --> hold ins, replete @ 20-30mEq/hr 3.3-5.3 --> use ins, replete @ 20-30mEq/hr >5.3 ------> dont give K+ until falls below uln